1. Recent PE Research
A.
PE and DVT in Pts Hospitalized With Syncope: A Multicenter Cross-sectional
Study in Toronto, Ontario, Canada
Verma AA, et
al. JAMA Intern Med. Published online May 8, 2017.
This study is a response
to Prandoni et al. NEJM 2017 here: https://www.ncbi.nlm.nih.gov/pubmed/27797317
The
prevalence of pulmonary embolism (PE) among patients hospitalized with syncope
is uncertain. The recently published Pulmonary Embolism in Syncope Italian
Trial (PESIT)1 systematically evaluated patients hospitalized with a first
episode of syncope and determined that 17.3% had a PE. It is not known how
commonly patients hospitalized with syncope are investigated for PE or deep
venous thrombosis (DVT) in routine practice.
Methods | We
conducted a retrospective cross-sectional study at 4 hospital sites in Toronto,
Ontario, Canada, that were participating in the General Medicine Inpatient
(GEMINI) cohort study. The GEMINI study has linked electronic clinical data from
hospital information systems with administrative data to study patients cared
for by general medicine services in hospitals affiliated with the University of
Toronto. We applied the same inclusion and exclusion criteria as PESIT in all
general medicine patients hospitalized through the emergency department between
April 1, 2011, and March 31, 2015. In Canada, hospitals use International
Statistical Classification of Diseases and Related Health Problems, Tenth
Revision (ICD-10), codes to designate 1 primary diagnosis for the emergency department
visit and 1 primary diagnosis at hospital discharge for mandatory reporting to
the Canadian Institute for Health Information. The emergency department and
hospital discharge diagnoses are not necessarily the same. We included patients
if their primary diagnosis was syncope in either the emergency department or at
hospital discharge, using the ICD-10 code R55. We excluded patients who were receiving
anticoagulation at admission, had prior syncope, or were pregnant.
The main outcomes
were the occurrence of investigation for venous thromboembolism (VTE) during hospitalization,
defined as testing with a plasma D-dimer level, compression ultrasonography of
the upper or lower limbs, computed tomographic pulmonary angiography (
CTPA), or ventilation
perfusion (V/Q) scan, and the diagnostic yield of these investigations. Because
there is substantial overlap in the investigation and management of DVT and PE,
we examined a composite of all investigations for VTE. The GEMINI study
received research ethics board approval from all participating hospitals.
Results | Of
the 1650 patients hospitalized with syncope, 345 were excluded (179 with
preadmission anticoagulation and 166 with previous syncope), and the final
cohort included 1305 patients. At least 1 investigation for VTE was performed
in 146 patients (11.2% [95%CI, 9.6%-13.0%]) (Table 1), including 120 who
received imaging with CTPA, V/Q scan, and/or compression ultrasonography (9.2%
[95% CI, 7.8%-10.9%]). Pulmonary embolism was diagnosed in 11 of the 73 patients
who received a CTPA or V/Q scan, and DVT was diagnosed in 10 of the 67 patients
who received ultrasonography, representing a diagnostic yield of 15.1% (95% CI,
8.6%-25.0%) and 14.9% (95% CI, 8.3%-25.4%), respectively. The prevalence of VTE
in the cohort was 1.4% (95% CI, 0.9%-2.2%) (Table 2).
Discussion |
In a large observational study, VTE was investigated in 11.2% of patients
hospitalized with syncope. The diagnostic yield for VTE was 15.0% and the
prevalence was 1.4%, not 41.9% and 17.1%, respectively, as found in the PESIT
study.1 Our findings call into question the generalizability of the PESIT results.The1.4%prevalence
of VTE we found is consistent with previously published estimates, which range
from 0.9% to 2.8%.2-4 Unlike the case in PESIT, all patients were not screened for
VTE in our study or in these previous studies; thus, the prevalence may have
been underestimated. A more illuminating comparison, however, is to examine the
diagnostic yield of imaging for VTE. We expected that thrombosis would be more
likely in the selected patients who received imaging for VTE based on clinical
judgment in our study, not in the large proportion (40.9%) of patients who received
imaging based on screening, as was the case in PESIT. The reverse was true,
highlighting the differences in the study populations…
Assessing all
patients hospitalized with syncope for VTE would represent a substantial
departure from conventional practice. Based on the available data, there is
little, if any, justification for routine testing for VTE in all patients
hospitalized with a first episode of syncope.
Full-text
(subscription required): http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2626191
B.
Low Yield of CTPA in the ED When Providers Override Evidence-based CDS.
Yan Z, et al.
Radiology. 2017 Mar;282(3):717-725.
Purpose To
determine the frequency of, and yield after, provider overrides of
evidence-based clinical decision support (CDS) for ordering computed
tomographic (CT) pulmonary angiography in the emergency department (ED).
Materials and
Methods This HIPAA-compliant, institutional review board-approved study was
performed at a tertiary care, academic medical center ED with approximately 60
000 annual visits and included all patients who were suspected of having
pulmonary embolism (PE) and who underwent CT pulmonary angiography between
January 1, 2011, and August 31, 2013. The requirement to obtain informed
consent was waived. Each CT order for pulmonary angiography was exposed to CDS
on the basis of the Wells criteria. For patients with a Wells score of 4 or
less, CDS alerts suggested d-dimer testing because acute PE is highly unlikely
in these patients if d-dimer levels are normal. The yield of CT pulmonary
angiography (number of positive PE diagnoses/total number of CT pulmonary
angiographic examinations) was compared in patients in whom providers overrode
CDS alerts (by performing CT pulmonary angiography in patients with a Wells
score ≤4 and a normal d-dimer level or no d-dimer testing) (override group) and
those in whom providers followed Wells criteria (CT pulmonary angiography only
in patients with Wells score over 4 or ≤4 with elevated d-dimer level) (adherent
group). A validated natural language processing tool identified positive PE
diagnoses, with subsegmental and/or indeterminate diagnoses removed by means of
chart review. Statistical analysis was performed with the χ2 test, the Student
t test, and logistic regression.
Results Among
2993 CT pulmonary angiography studies in 2655 patients, 563 examinations had a
Wells score of 4 or less but did not undergo d-dimer testing and 26 had a Wells
score of 4 or less and had normal d-dimer levels. The yield of CT pulmonary
angiography was 4.2% in the override group (25 of 589 studies, none with a
normal d-dimer level) and 11.2% in the adherent group (270 of 2404 studies) (P less
than .001). After adjustment for the risk factor differences between the two
groups, the odds of an acute PE finding were 51.3% lower when providers
overrode alerts than when they followed CDS guidelines. Comparison of the two
groups including only patients unlikely to have PE led to similar results.
Conclusion
The odds of an acute PE finding in the ED when providers adhered to evidence
presented in CDS were nearly double those seen when providers overrode CDS
alerts. Most overrides were due to the lack of d-dimer testing in patients
unlikely to have PE.
C.
Low yield of ventilation and perfusion imaging for the evaluation of PE after
indeterminate CT PA.
Curtis BR, et
al. Emerg Radiol. 2017 Apr 12 [Epub ahead of print].
PURPOSE:
Ventilation and perfusion (VQ) imaging is common following suboptimal CT
pulmonary angiogram (CTPA) for pulmonary embolism (PE) evaluation; however, the
results of this diagnostic pathway are unclear. The purpose of our study is to
determine the incidence of PE diagnosed on VQ scans performed in patients with
suboptimal CTPAs.
METHODS: One
hundred twenty-two suboptimal CTPAs with subsequent VQ scans within 1 week were
retrospectively identified. VQ reports utilizing modified prospective
investigation of pulmonary embolism diagnosis (PIOPED) and prospective
investigative study of acute pulmonary embolism diagnosis (PISAPED) criteria
were evaluated for presence of PE; intermediate probability, high probability,
and PE present were considered PE positive. Three hundred consecutive reports
of each diagnostic CTPA and diagnostic VQ studies were reviewed to estimate
baseline PE positive rates at our institution. These were compared to the
positive VQ scan rate after suboptimal CTPA by Fisher's exact test. Reported
reason for suboptimal CTPA was noted. When contrast bolus timing was
suboptimal, we measured main pulmonary artery (mPA) Hounsfield units (HU).
Potential alternative diagnoses in CTPA reports were noted.
RESULTS:
97.5% (119/122) of VQ scans following suboptimal CTPA were negative for PE, and
2.5% (3/122) were positive for PE. This was significantly lower than baseline
PE positive rate of 10.7% (32/300, p less than 0.01) for VQ imaging, and 10.3%
(31/300, p less than 0.01) for CTPA at our institution. Most (79.5%) CTPAs were
suboptimal due to contrast timing. Average mPA density in these cases was 164 ±
61 HU. Most of these studies ruled out central PE. Potential alternative
diagnosis was reported in 34/122 (28%) of suboptimal CTPAs, for which pneumonia
accounted 59%.
CONCLUSION:
There is very low incidence of PE diagnosed on VQ imaging performed after
suboptimal CTPA. This may be attributed to the ability of most suboptimal CTPAs
to rule out central PE.
2. Outcomes for ED Patients With Recent-Onset AF/FL Treated in
Canadian Hospitals.
Stiell IG, et
al. Ann Emerg Med. 2017 May;69(5):562-571.e2.
STUDY
OBJECTIVE: Recent-onset atrial fibrillation and flutter are the most common
arrhythmias managed in the emergency department (ED). We evaluate the
management and 30-day outcomes for recent-onset atrial fibrillation and flutter
patients in Canadian EDs, where cardioversion is commonly practiced.
METHODS: We
conducted a prospective cohort study in 6 academic hospital EDs and enrolled
patients who had atrial fibrillation and flutter onset within 48 hours.
Patients were followed for 30 days by health records review and telephone.
Adverse events included death, stroke, acute coronary syndrome, heart failure,
subsequent admission, or ED electrocardioversion.
RESULTS: We
enrolled 1,091 patients with mean age 63.9 years, atrial fibrillation 84.7%,
atrial flutter 15.3%, hospital admission 9.0%, and converted to sinus rhythm
80.1%. Although 10.5% of recent-onset atrial fibrillation and flutter patients
had adverse events within 30 days, there were no related deaths and 1 stroke
(0.1%). Adjusted odds ratios for factors associated with adverse event were
hours from onset (1.03/hour; 95% confidence interval [CI] 1.01 to 1.05),
history of stroke or transient ischemic attack (2.09; 95% CI 1.01 to 4.36), and
pulmonary congestion on chest radiograph (7.37; 95% CI 2.40 to 22.64). Patients
who left the ED in sinus rhythm were much less likely to experience an adverse
event (P less than .001).
CONCLUSION:
Although most recent-onset atrial fibrillation and flutter patients were
treated aggressively in the ED, there were few 30-day serious outcomes.
Physicians underprescribed oral anticoagulants. Potential risk factors for
adverse events include longer duration from arrhythmia onset, previous stroke
or transient ischemic attack, pulmonary congestion on chest radiograph, and not
being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration
and discharge in most patients is effective and safe.
3. CPR Research
A.
Bystander Efforts Improve 1-Year Outcomes in Out-of-Hospital Cardiac Arrest.
Kragholm K,
et al. N Engl J Med. 2017 May 4;376(18):1737-1747.
BACKGROUND: The
effect of bystander interventions on long-term functional outcomes among
survivors of out-of-hospital cardiac arrest has not been extensively studied.
METHODS: We
linked nationwide data on out-of-hospital cardiac arrests in Denmark to
functional outcome data and reported the 1-year risks of anoxic brain damage or
nursing home admission and of death from any cause among patients who survived
to day 30 after an out-of-hospital cardiac arrest. We analyzed risks according
to whether bystander cardiopulmonary resuscitation (CPR) or defibrillation was
performed and evaluated temporal changes in bystander interventions and
outcomes.
RESULTS: Among
the 2855 patients who were 30-day survivors of an out-of-hospital cardiac
arrest during the period from 2001 through 2012, a total of 10.5% had brain
damage or were admitted to a nursing home and 9.7% died during the 1-year
follow-up period. During the study period, among the 2084 patients who had cardiac
arrests that were not witnessed by emergency medical services (EMS) personnel,
the rate of bystander CPR increased from 66.7% to 80.6% (P less than 0.001),
the rate of bystander defibrillation increased from 2.1% to 16.8% (P less than 0.001),
the rate of brain damage or nursing home admission decreased from 10.0% to 7.6%
(P less than 0.001), and all-cause mortality decreased from 18.0% to 7.9%
(P=0.002). In adjusted analyses, bystander CPR was associated with a risk of
brain damage or nursing home admission that was significantly lower than that
associated with no bystander resuscitation (hazard ratio, 0.62; 95% confidence
interval [CI], 0.47 to 0.82), as well as a lower risk of death from any cause
(hazard ratio, 0.70; 95% CI, 0.50 to 0.99) and a lower risk of the composite
end point of brain damage, nursing home admission, or death (hazard ratio,
0.67; 95% CI, 0.53 to 0.84). The risks of these outcomes were even lower among
patients who received bystander defibrillation as compared with no bystander
resuscitation.
CONCLUSIONS: In
our study, we found that bystander CPR and defibrillation were associated with
risks of brain damage or nursing home admission and of death from any cause
that were significantly lower than those associated with no bystander
resuscitation.
B.
Practice guideline summary: Reducing brain injury following CPR: Report of the
Guideline Development, Dissemination, and Implementation Subcommittee of the
American Academy of Neurology.
Geocadin RG,
et al. Neurology. 2017 May 10 [Epub ahead of print].
OBJECTIVE: To
assess the evidence and make evidence-based recommendations for acute
interventions to reduce brain injury in adult patients who are comatose after
successful cardiopulmonary resuscitation.
METHODS: Published
literature from 1966 to August 29, 2016, was reviewed with evidence-based
classification of relevant articles.
RESULTS AND
RECOMMENDATIONS: For patients who are comatose in whom the initial cardiac
rhythm is either pulseless ventricular tachycardia (VT) or ventricular
fibrillation (VF) after out-of-hospital cardiac arrest (OHCA), therapeutic
hypothermia (TH; 32-34°C for 24 hours) is highly likely to be effective in
improving functional neurologic outcome and survival compared with non-TH and
should be offered (Level A). For patients who are comatose in whom the initial
cardiac rhythm is either VT/VF or asystole/pulseless electrical activity (PEA)
after OHCA, targeted temperature management (36°C for 24 hours, followed by 8
hours of rewarming to 37°C, and temperature maintenance below 37.5°C until 72 hours)
is likely as effective as TH and is an acceptable alternative (Level B). For
patients who are comatose with an initial rhythm of PEA/asystole, TH possibly
improves survival and functional neurologic outcome at discharge vs standard
care and may be offered (Level C). Prehospital cooling as an adjunct to TH is
highly likely to be ineffective in further improving neurologic outcome and
survival and should not be offered (Level A). Other pharmacologic and
nonpharmacologic strategies (applied with or without concomitant TH) are also
reviewed.
4. Time to Treatment and Mortality during Mandated Emergency
Care for Sepsis.
Seymour CW,
et al. N Engl J Med. 2017 May 21 [Epub ahead of print].
Background In
2013, New York began requiring hospitals to follow protocols for the early
identification and treatment of sepsis. However, there is controversy about
whether more rapid treatment of sepsis improves outcomes in patients.
Methods We
studied data from patients with sepsis and septic shock that were reported to
the New York State Department of Health from April 1, 2014, to June 30, 2016.
Patients had a sepsis protocol initiated within 6 hours after arrival in the
emergency department and had all items in a 3-hour bundle of care for patients
with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and
lactate measurement) completed within 12 hours. Multilevel models were used to
assess the associations between the time until completion of the 3-hour bundle
and risk-adjusted mortality. We also examined the times to the administration
of antibiotics and to the completion of an initial bolus of intravenous fluid.
Results Among
49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle
completed within 3 hours. The median time to completion of the 3-hour bundle
was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the
administration of antibiotics was 0.95 hours (interquartile range, 0.35 to
1.95), and the median time to completion of the fluid bolus was 2.56 hours
(interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed
within 12 hours, a longer time to the completion of the bundle was associated
with higher risk-adjusted in-hospital mortality (odds ratio, 1.04 per hour; 95%
confidence interval [CI], 1.02 to 1.05; P less than 0.001), as was a longer
time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI,
1.03 to 1.06; P less than 0.001) but not a longer time to the completion of a
bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02;
P=0.21).
Conclusions
More rapid completion of a 3-hour bundle of sepsis care and rapid
administration of antibiotics, but not rapid completion of an initial bolus of
intravenous fluids, were associated with lower risk-adjusted in-hospital
mortality. (Funded by the National Institutes of Health and others.).
5. From the Blogosphere
A.
Lit Review: Safety of ondansetron in pregnancy
Mark Mixon, PharmD,
Emergency Medicine, May 11, 2017
Introduction
Nausea and
vomiting is a common ailment in pregnancy affecting approximately 70 to 80% of
all pregnant women. (1) Ondansetron, a 5-HT3 receptor antagonist, is commonly
used to treat nausea and vomiting of varying etiologies including hyperemesis
gravidarum. (2) Recently the safety of ondansetron in pregnancy has been called
into question. Concern for fetal abnormalities, including cardiac malformations
and cleft palates caused by ondansetron have been raised, leading to a petition
to the Food and Drug Administration (FDA) to reclassify the agent to category
C, D, or X from its current pregnancy category of B. (3) Below we review the
pertinent data surrounding the safety of ondansetron in pregnancy…
Conclusion
The largest
and most well designed study showed no difference in any major birth defect and
no cleft palates in those exposed to ondansetron in the first trimester. (4)
Studies suggesting ondansetron may cause cardiac malformations were not well
designed, failing to adjust for maternal co-morbidities that could themselves
cause cardiac malformations, or were not published in peer reviewed journals,
only as abstracts. (5-6) The one study suggesting ondansetron exposure may
increase the risk of cleft palates was poorly designed and contained a very
small number of patients. (7) The FDA has refused to change the current
pregnancy category for ondansetron from a “B” given this evidence. (3) Based on the current data, ondansetron
appears to be a safe agent for the treatment of nausea and vomiting the
pregnancy.
When asked
about the safety of ondansetron in pregnancy by patients, providers or other
emergency department personnel, one can advise that the best available data
shows no increase in congenital defects. The benefit of ondansetron use likely
outweighs its risk, especially taking into account the adverse fetal effects
that maternal electrolyte abnormalities, dehydration, and nutritional
deficiency caused by nausea/vomiting may cause. If ondansetron therapy is
refused other possible treatment options include pyridoxine, H1-receptor
antagonists such as doxylamine, diphenhydramine, and meclizine, or dopamine
receptor antagonists such as metoclopramide, promethazine, and
prochlorperazine.
B.
Resuscitationist’s Guide to Status Epilepticus
Josh Farkas, EMCrit
· May 8, 2017
In 2014 I
wrote a post suggesting an aggressive, streamlined approach to status
epilepticus involving early intubation. The fundamentals of that post remain
valid. However, much has changed over the last few years. This post aims to
refresh and extend the prior post. It will also serve as a reference to explain
my algorithm for status epilepticus in the upcoming Resuscitationist's Crisis
Manual.
Overview
& philosophy
There are
many ways to manage status epilepticus.
Rather than focusing on what may be the theoretically ideal, this post
explores an approach which is effective, safe, and feasible. It's easy to write an algorithm that looks
pretty on paper, but harder to create one that works in a crisis. For example, it's easy to write “administer fosphenytoin
after 10 minutes.” However, the
logistics of ordering the drug, receiving it from pharmacy, infusing it at the
correct rate, and allowing the body to metabolize it into active phenytoin can
take an hour.
The rationale
for aggressive treatment of generalized status epilepticus was described
previously here. In short, best outcomes
rely upon rapid seizure control. The
longer the seizure continues, the more refractory it becomes to therapy. The duration of status epilepticus which may
cause permanent brain damage is unknown, with experts currently suggesting
thirty minutes (Zaccara 2017). Aside
from the brain, persistent status epilepticus may cause aspiration,
hyperkalemia, rhabdomyolysis, hyperthermia, myocardial infarction, and
arrhythmia…
Speaking
of seizure management…
C.
Intravenous Versus Nonintravenous Benzodiazepines for the Cessation of
Seizures: A Systematic Review and Meta-analysis of RCTs
Alshehri A,
et al. Acad Emerg Med. 2017 Mar 25 [Epub ahead of print].
BACKGROUND:
The acquisition of intravenous (IV) access in the actively convulsing patient
is difficult. This often delays the administration of the IV benzodiazepine
(BDZ) necessary for seizure cessation. Delays in seizure cessation are
associated with increased pharmacoresistance, increased risk of neuronal
injury, worse patient outcomes, and increased morbidity.
OBJECTIVE:
The objective was to assess whether the delay imposed by IV access acquisition
is justified by improved outcomes. We compared IV versus non-IV BDZ efficacy in
the real world with regard to failure rates (primary outcome), interval to
seizure control, and observed complications (secondary outcomes).
METHODS: A
systematic review was performed using Medline, Embase, and the Cochrane
Library. All studies published or in press from the inception of the respective
database to July 2016 were included. Only randomized and quasi-randomized
controlled trials directly comparing IV to non-IV (buccal, rectal, intranasal,
or intramuscular) BDZ were included.
RESULTS: Our
search strategy retrieved 2,604 citations for review. A total of 11 studies
were finally included in qualitative synthesis and 10 in quantitative analysis.
Only one was of high quality. For treatment failure, non-IV BDZ was superior to
IV BDZ (odd ratio [OR] = 0.72; 95% confidence interval [CI] = 0.56-0.92).
However, no significant difference was found between the two treatments in the
pediatric subgroup (OR = 1.16; 95% CI = 0.74-1.81). Non-IV BDZ was administered
faster than IV BDZ and therefore controlled seizures faster (mean difference =
3.41 minutes; 95% CI = 1.69-5.13 minutes) despite a longer interval between drug
administration and seizure cessation (mean difference = 0.74 minutes; 95% CI =
0.52-0.95 minutes). Respiratory complications requiring intervention were
similar between non-IV BDZ and IV BDZ, regardless of administration route (risk
difference = 0.00; 95% CI = -0.02 to 0.01).
CONCLUSION:
Non-IV BDZ, compared to IV BDZ, terminate seizures faster and have a superior
efficacy and side effect profile. Higher-quality studies and further evaluation
in different age groups are warranted.
6. Diverticulitis: Can Some Pts Safely Forego Admission? And
Antibiotics?
A.
Diverticulitis Diagnosed in the Emergency Room: Is It Safe to Discharge Home?
Sirany AE, et
al. J Am Coll Surg. 2017 Mar 7 [Epub ahead of print].
BACKGROUND:
Inpatient treatment of patients with colon diverticulitis represents a
significant financial and clinical burden to the healthcare system and
patients. The aim of this study was compare patients with diverticulitis in the
emergency department (ED) who were discharged to home versus admitted to the
hospital.
STUDY DESIGN:
We reviewed all patients evaluated in the ED of a metropolitan health system
with the primary diagnosis of diverticulitis (ICD9 562.11) from 2010 through
2012. Only patients diagnosed with computed tomography and those with follow-up
were included.
RESULTS: We
identified 240 patients; 132 (55%) women, mean age was 59.1 (SD 16.1) years.
Imaging findings included extraluminal air (21%), pericolic or pelvic abscess
(12%), free fluid (16%), and pneumoperitoneum (6%). 144 (60%) were admitted to
the hospital and 96 (40%) were discharged to home on oral antibiotics. Patients
admitted to the hospital were more likely to be greater than 65 years
(p=0.0007), have a Charlson comorbidity score of over 2 (p=0.0025), to be on
steroids or immunosuppressed (p=0.0019), have extraluminal air (p less than 0.0001)
or diverticular abscess (p less than 0.0001) on imaging. Median follow-up for
all patients was 36.5 months (IQR 25.2- 43). Among patients discharged from the
ED, 12.5% returned to the ED or were readmitted within 30 days, with only one
patient (1%) requiring emergency surgery, but not until 20 months later.
Patients admitted to the hospital had similar rates of readmission (15%;
p=0.65).
CONCLUSION:
Patients diagnosed with uncomplicated diverticulitis in the emergency room can
be safely discharged home on oral antibiotics, as long as CT findings are
included in the decision- making process. Patients with complicated
diverticulitis on CT scan should be admitted to the hospital with surgical
consultation.
Related
study: Perhaps antibiotics are also unnecessary?
B.
Randomized clinical trial of observational versus antibiotic treatment for a
first episode of CT-proven uncomplicated acute diverticulitis.
Daniels L, et
al. Br J Surg. 2017 Jan;104(1):52-61.
BACKGROUND:
Antibiotics are advised in most guidelines on acute diverticulitis, despite a
lack of evidence to support their routine use. This trial compared the
effectiveness of a strategy with or without antibiotics for a first episode of
uncomplicated acute diverticulitis.
METHODS:
Patients with CT-proven, primary, left-sided, uncomplicated, acute
diverticulitis were included at 22 clinical sites in the Netherlands, and
assigned randomly to an observational or antibiotic treatment strategy. The
primary endpoint was time to recovery during 6 months of follow-up. Main
secondary endpoints were readmission rate, complicated, ongoing and recurrent
diverticulitis, sigmoid resection and mortality. Intention-to-treat and
per-protocol analyses were done.
RESULTS: A
total of 528 patients were included. Median time to recovery was 14 (i.q.r.
6-35) days for the observational and 12 (7-30) days for the antibiotic
treatment strategy, with a hazard ratio for recovery of 0·91 (lower limit of
1-sided 95 per cent c.i. 0·78; P = 0·151). No significant differences between
the observation and antibiotic treatment groups were found for secondary
endpoints: complicated diverticulitis (3·8 versus 2·6 per cent respectively; P
= 0·377), ongoing diverticulitis (7·3 versus 4·1 per cent; P = 0·183), recurrent
diverticulitis (3·4 versus 3·0 per cent; P = 0·494), sigmoid resection (3·8
versus 2·3 per cent; P = 0·323), readmission (17·6 versus 12·0 per cent; P =
0·148), adverse events (48·5 versus 54·5 per cent; P = 0·221) and mortality
(1·1 versus 0·4 per cent; P = 0·432). Hospital stay was significantly shorter
in the observation group (2 versus 3 days; P = 0·006). Per-protocol analyses
were concordant with the intention-to-treat analyses.
CONCLUSION:
Observational treatment without antibiotics did not prolong recovery and can be
considered appropriate in patients with uncomplicated diverticulitis.
7. Application of the MASCC and CISNE Risk-Stratification Scores
to Identify Low-Risk Febrile Neutropenic Pts in the ED
Coyne CJ, et
al. Ann Emerg Med. 2017; 69:755–764.
STUDY
OBJECTIVE: Although validated risk-stratification tools have been used to send
low-risk febrile neutropenic patients home from clinic and inpatient settings,
there is a dearth of research evaluating these scores in the emergency
department (ED). We compare the predictive accuracy of the Multinational
Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable
Febrile Neutropenia (CISNE) scores for patients with chemotherapy-induced
febrile neutropenia and presenting to the ED.
METHODS: We
conducted a retrospective cohort study to evaluate all patients with febrile
neutropenia (temperature ≥38°C [100.4°F], absolute neutrophil count less than 1,000
cells/μL) who presented to 2 academic EDs from June 2012 through January 2015.
MASCC and CISNE scores were calculated for all subjects, and each visit was
evaluated for several outcome variables, including inpatient length of stay,
upgrade in level of care, clinical deterioration, positive blood culture
results, and death. Descriptive statistics are reported and continuous
variables were analyzed with Wilcoxon rank sum.
RESULTS:
During our study period, 230 patients presented with chemotherapy-induced
febrile neutropenia. The CISNE score identified 53 (23%) of these patients as
low risk and was highly specific in the identification of a low-risk cohort for
all outcome variables (98.3% specific, 95% confidence interval [CI] 89.7% to
99.9%; positive predictive value 98.1%, 95% CI 88.6% to 99.9%). Median length
of stay was shorter for low-risk versus high-risk CISNE patients (3-day
difference; P less than .001). The MASCC score was much less specific (54.2%;
95% CI 40.8% to 67.1%) in the identification of a low-risk cohort.
CONCLUSION:
Our results suggest that the CISNE score may be the most appropriate febrile
neutropenia risk-stratification tool for use in the ED.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(16)31352-X/fulltext
8. On Physician Work Schedules and Payment Models
A.
The Effect of Discrete Work Shifts on a Nonterminating Service System
Batt RJ, et
al. 2017 Wisconsin University
Hospital
emergency departments (EDs) provide around-the-clock medical care and as such
are generally modeled as nonterminating queues. However, from the care
provider’s point of view, ED care is not a never-ending process, but rather
occurs in discrete work shifts and may require passing unfinished work to the
next care provider at the end of the shift. We use data from a large, academic
medical center ED to show that the patient hazard rate of service completion
varies over the course of the shift, and as a result, a patient’s expected
treatment time is impacted by when in the doctor’s shift treatment begins.
We
also show that treatment time increases with self-multitasking (the number of
patients currently in process with the focal physician), but decreases with
co-worker multitasking (the number of patients currently in process with all
other physicians). The magnitude of the self-multitasking effect is much
larger. Lastly, we show that while treatment time is unaffected by an
end-of-shift handoff, patients that have been handed off are more likely to
revisit the ED within 3 days, suggesting that patient handoffs lower clinical quality.
We use simulation to show that implementing “no new patients” cutoff times can
be beneficial in terms of productivity and reduced patient handoffs.
Full-text
(free): https://wsbfiles.bus.wisc.edu/digital/rjbatt/intellcont_journal/Batt%20et%20al%20Discrete_Work_Shifts-1.pdf
B.
Replacing fee-for-service with salary might improve care, reduce burnout
Jeff Lagasse,
Associate Editor; Healthcare Finance. May 10, 2017
Economists
George Loewenstein and Ian Larkin argue that paying physicians a salary instead
of a fee for each service would reduce overuse of tests and procedures. It
could also improve their job satisfaction and focus on care.
Economists
propose paying physicians salary over fee-for-service method to avoid conflicts
of interest Fee-for-service compensation arrangements, they propose, create
incentives for physicians to order more services than are best for patients.
In a Journal
of the American Medical Association Viewpoint article, a pair of behavioral
economists contend that doctors should be paid by salary, rather than the
fee-for-service arrangements under which most of them now operate.
While most
conflict of interest research and debate in medicine tends to focus on
physicians interacting with pharmaceutical and device companies, how doctors
are paid is one important source of conflict that's largely ignored in medical
literature, they said.
Fee-for-service
compensation arrangements, they propose, create incentives for physicians to
order more, and different, services than are best for patients.
"Paying
doctors to do more leads to over-provision of tests and procedures, which cause
harms that go beyond the monetary and time costs of getting them," said
George Loewenstein, the Herbert A. Simon University professor of economics and psychology
at Carnegie Mellon University, in a statement. "Many if not most tests and
procedures cause pain and discomfort, especially when they go wrong."
He and Ian
Larkin, an assistant professor of strategy at UCLA's Anderson School of
Management, said that a commonly proposed solution to the problem involves
requiring physicians to disclose their financial interest for a given
procedure. But disclosure of conflicts has been found to have limited, or even
negative, effects on patients.
Loewenstein
and Larkin argue that the simplest and most effective way to deal with
conflicts caused by fee-for-service arrangements is to pay physicians on a
straight salary basis. Several health systems well-known for high quality of
care, such as the Mayo Clinic, the Cleveland Clinic and the Kaiser group in
California, pay physicians salaries without incentives for volume of services
performed.
Moving more
physicians to straight salary-based compensation might have benefits not only
for patients, but also for physicians themselves, they said.
"The
high levels of job dissatisfaction reported by many physicians may result, in
part, from the need to navigate the complexities of the fee-for-service
arrangements," said Larkin. "Instead of focusing on providing
patients with the best possible medical care, physicians are forced to consider
the ramifications of their decisions for their own paychecks."
9. Controversies in TIA Evaluation and Disposition in the ED
Long B, et
al. J Emerg Med. 2017;52(3):299-310.
Background:
Transient ischemic attack (TIA) affects over 200,000 patients annually in the
United States, and it precedes approximately 14% to 23% of strokes. Patients
are typically admitted for evaluation and management.
Objective:
This review investigates the controversies of emergency department (ED)
evaluation of TIA, including imaging, clinical risk scores, rapid diagnostic
protocols, and disposition.
Discussion:
TIA is a common condition, with over 200,000 patients affected annually, and is
associated with risk of stroke. TIA is defined as a brief episode of neurologic
dysfunction with no permanent infarction. A great deal of literature has
evaluated the use of imaging, clinical risk scores, and diagnostic protocols in
the evaluation of TIA. Head computed tomography noncontrast is not reliable to
diagnose acute infarction. Magnetic resonance imaging with diffusion-weighted
imaging displays greater diagnostic ability. Carotid imaging includes magnetic
resonance angiography, computed tomography angiography, and Doppler with
ultrasound. Risk scores that predict future stroke are not reliable when
utilized alone. With imaging, including magnetic resonance imaging, patients
with low-risk scores can be discharged. The use of ED diagnostic protocols and
observation units can reduce length of stay while improving patient treatment
and reducing stroke rate. An algorithm is provided for evaluation and
disposition in the ED.
Conclusions:
TIA is a condition with high risk for stroke. Imaging is often not reliable,
nor is the use of risk scores alone. The American College of Emergency
Physicians provides a Level B Recommendation for the use of rapid diagnostic
protocols to determine patient short-term risk for stroke while avoiding the
reliance on stratification instruments to discharge patients from the ED.
10. Images in Clinical Practice
Image
diagnosis: Iliopsoas abscess from Crohn disease.
ECG: Male
With Chest Pain and Lightheadedness
ECG: Unresponsive
Male
Melanoma of
the foot
Binaural
Tympanic-Membrane Perforations after Blast Injury
Traumatic
Spondylolisthesis of the Axis (Hangman’s Fx)
Pyogenic
Granuloma of the Conjunctiva
Scarlet Fever
Tuberous
Sclerosis Complex
Female With
Pain in the Right Shoulder and Chest
Young Infant
With Vomiting
Adolescent
Female With Headache and Nausea
Woman With
Severe Headache
Postural
Headache? It’s Not a Tumor!
Earlobe
Crease in Patient With Chest Pain
Elderly Male
With Neck Stiffness and Fever
Adolescent
Female With Abdominal Pain
Man With
Painless Oral Lesions
12. Reflections on Physician Experience
A.
Letter to a Young Female Physician
Suzanne
Koven, M.D. N Engl J Med 2017; 376:1907-1909.
This past
June, I participated in an orientation session during which new interns were
asked to write self-addressed letters expressing their hopes and anxieties. The
sealed envelopes were collected and then returned 6 months later, when I’m sure
the interns felt encouraged to see how far they’d come.
This
exercise, in which the intern serves as both letter writer and recipient, both
novice and veteran, offers a new twist on an old tradition. In 1855, James
Jackson published Letters to a Young Physician Just Entering Upon Practice.
More recent additions to this epistolary canon include Richard Selzer’s Letters
to a Young Doctor, which appeared in 1982, and Treatment Kind and Fair: Letters
to a Young Doctor, which Perri Klass published in 2007 on the occasion of her
son’s entry into medical school.
When I
started my internship 30 years ago, I wasn’t invited to share my hopes and
anxieties in a letter — or anywhere else, for that matter. In fact, I recall no
orientation at all, other than lining up to receive a stack of ill-fitting
white uniforms, a tuberculin skin test, and a hasty and not particularly
reassuring review of CPR.
Perhaps the
memory of my own abrupt initiation explains my response as I sat at the
conference table watching the new interns hunched earnestly over their letters:
I was filled with longing. I wanted so much to tell them, particularly the
women — more than half the group, I was pleased to note — what I wished I’d
known. Even more, I yearned to tell my younger self what I wished I’d known. As
the interns wrote, I composed a letter of my own.
Dear Young Female Physician:
I know you
are excited and also apprehensive. These feelings are not unwarranted. The
hours you will work, the body of knowledge you must master, and the
responsibility you will bear for people’s lives and well-being are daunting.
I’d be worried if you weren’t at least a little worried.
As a woman,
you face an additional set of challenges, but you know that already. On your
urology rotation in medical school, you were informed that your presence was
pointless since “no self-respecting man would go to a lady urologist.”
There will be
more sexism, some infuriating, some merely annoying. As a pregnant resident, I
inquired about my hospital’s maternity-leave policy for house officers and was
told that it was a great idea and I should draft one. Decades into practice,
when I call in a prescription, some pharmacists still ask for the name of the
doctor I’m calling for.
And there
will be more serious and damaging discrimination as well. It pains me to tell
you that in 2017, as I’m nearing the end of my career, female physicians earn
on average $20,000 less than our male counterparts (even allowing for factors
such as numbers of publications and hours worked)1; are still underrepresented
in leadership positions, even in specialties such as OB–GYN in which we are a
majority2; and are subjected to sexual harassment ranging from unwelcome “bro”
humor in operating rooms and on hospital rounds to abuse so severe it causes
some women to leave medicine altogether.3
But there’s
also a more insidious obstacle that you’ll have to contend with — one that
resides in your own head. In fact, one of the greatest hurdles you confront may
be one largely of your own making. At least that has been the case for me. You
see, I’ve been haunted at every step of my career by the fear that I am a
fraud.
This fear,
sometimes called “imposter syndrome,” is not unique to women. Your male
colleagues also have many moments of insecurity, when they’re convinced that
they alone among their peers are incapable of understanding the coagulation
pathway, tying the perfect surgical knot, or detecting a subtle heart murmur.
I believe
that women’s fear of fraudulence is similar to men’s, but with an added
feature: not only do we tend to perseverate over our inadequacies, we also
often denigrate our strengths.
A 2016 study
suggested that patients of female physicians have superior outcomes.4 The
publication of that finding prompted much speculation about why it might be so:
perhaps women are more intuitive, more empathic, more attentive to detail,
better listeners, or even kinder? I don’t know whether any of those
generalizations are true, but my personal experience and observations make me
sure of this: when women do possess these positive traits, we tend to discount
their significance and may even consider them liabilities. We assume that
anyone can be a good listener, be empathic — that these abilities are nothing
special and are the least of what we have to offer our patients.
I have wasted
much time and energy in my career looking for reassurance that I was not a
fraud and, specifically, that I had more to offer my patients than the
qualities they seemed to value most.
Early on, I
believed that displaying medical knowledge — the more obscure the better —
would make me worthy. That belief was a useful spur to learning, but ultimately
provided only superficial comfort. During my second-year clinical skills
course, an oncologist asked me to identify a rash. “Mycosis fungoides!” I
blurted out, since it was one of the few rashes whose name I knew and the only
one associated with cancer. My answer turned out to be correct, causing three
jaws to drop at once — the oncologist’s, the patient’s, and my own — but the
glow of validation lasted barely the rest of the day.
A little
further on in training, I thought that competence meant knowing how to do
things…
B.
Board Review and the Middle-Aged Doctor: What Develops with Life Experience
Anna Reisman,
M.D. N Engl J Med 2017; 376:1612-1613
Middle age is
the best age to be in this difficult profession, because we are old enough to
have suffered ourselves or to have witnessed the suffering of people we love
and yet young enough to have the opportunity to pay forward this heightened
sensitivity…
Middle age
can awaken something like compassion, but it’s more than that. The German word
mitgefühl, “with feeling,” marries compassion with condolences, commiseration,
and sympathy; the prefix “mit,” or “with,” avows the togetherness, the
accompaniment, what the psychiatrist Christine Montross calls abiding with
patients. In middle age, that feeling can augment our ability to be there for,
to be with our patients, because we may have been there ourselves, or somewhere
close enough that we can relate. Imagining the doctor I’d want to have when
facing a serious illness, I’d prefer one with a few wrinkles and a greater
reserve of lived experience…
13. US-guided interscalene nerve block vs procedural sedation by
propofol and fentanyl for anterior shoulder dislocations.
Raeyat Doost
E, et al. Am J Emerg Med. 2017 Apr 14 [Epub ahead of print]
BACKGROUND:
Few studies were performed to compare ultrasound guided brachial plexus block
with procedural sedation for reduction of shoulder dislocations in the
Emergency Department (ED). This study was done to provide further evidence
regarding this comparison.
METHODS: This
was a randomized clinical trial performed on patients presenting with anterior
shoulder dislocations to the emergency department of an academic level 2 trauma
center. Exclusion criteria were any contraindications to the drugs used, any
patient which may not be potentially assigned into both groups because of an
underlying medical condition, presence of neurovascular compromise related to
the dislocation, presence of concomitant fractures, and patient refusal to
participate in the study. Patients were randomly assigned into the Procedural
Sedation and Analgesia (PSA) group with propofol and fentanyl or ultrasound
guided Inter-Scalene Brachial Plexus Block (ISBPB) with lidocaine and
epinephrine.
RESULTS: A
total of 60 patients (30 in each group) were included in the study. The
emergency room length of stay was significantly lower in the ISBPB group, with
mean (SD) values of 108.6 (42.1) vs. 80.2 (25.2) minutes (p=0.005). However,
pain scores in the PSA group during reduction showed advantage over ISBPB [0.38
vs. 3.43 (p less than 0.001)]. Moreover, patient satisfaction was higher with
PSA (p less than 0.001).
CONCLUSION:
Using ISBPB for reduction of anterior shoulder dislocations takes less time to discharge
and may make it more feasible in conditions mandating faster discharge of the
patient. However, since pain scores may be lower using PSA, this method may be
preferred by many physicians in some other situations.
14. Quick Lit Reviews by Ann Emerg Med
A.
In Patients With Cardiac Arrest, Does Amiodarone or Lidocaine Increase
Meaningful Survival?
Take-Home
Message: Among out-of-hospital cardiac arrest patients with shock-refractory
ventricular tachycardia or ventricular fibrillation, neither amiodarone nor
lidocaine increases survival to hospital discharge or good neurologic outcome.
B.
Does Rocuronium Create Better Intubating Conditions Than Succinylcholine for
Rapid Sequence Intubation?
Take-Home
Message: Succinylcholine is superior to rocuronium in providing excellent
intubating conditions for emergency rapid sequence intubation.
C.
Comparison of Fresh Frozen Plasma With Prothrombin Complex Concentrate for
Warfarin Reversal
Take-Home
Message: In patients with intracranial bleeding, prothrombin complex
concentrates may have a mortality benefit over fresh frozen plasma for the
reversal of warfarin.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(16)31334-8/fulltext
D.
Should Antiepileptic Drugs Be Initiated in the Emergency Department After a
First-Time Seizure?
Take-Home
Message: Immediate initiation of antiepileptic drug treatment after an
unprovoked first-time seizure may decrease the rate of recurrent seizure, but
does not otherwise affect long-term prognosis and is associated with adverse
events.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(16)31026-5/fulltext
E.
Do α2-Adrenergic Agonists Decrease the Symptoms Associated With Opioid
Withdrawal?
Take-Home
Message: α2-Adrenergic agonists (eg, clonidine) are associated with lower rates
of severe withdrawal symptoms and higher rates of adherence; however, this must
be balanced with known adverse effects such as hypotension.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(16)31027-7/fulltext
15. ED Airway Management of Severe Angioedema: A Video Review of
45 Intubations.
Driver BE, et
al. Ann Emerg Med. 2017 May;69(5):635-639.
STUDY
OBJECTIVE: Angioedema is an uncommon but important cause of airway obstruction.
Emergency airway management of angioedema is difficult. We seek to describe the
course and outcomes of emergency airway management for severe angioedema in our
institution.
METHODS: We
performed a retrospective, observational study of all intubations for
angioedema performed in an urban academic emergency department (ED) between
November 2007 and June 2015. We performed a structured review of video
recordings of each intubation. We identified the methods of airway management,
the success of each method, and the outcomes and complications of the effort.
RESULTS: We
identified 52 patients with angioedema who were intubated in the ED; 7 were
excluded because of missing videos, leaving 45 patients in the analysis. Median
time from arrival to the ED to the first intubation attempt was 33 minutes
(interquartile range 17 to 79 minutes). Nasotracheal intubation was the most
common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%).
Two patients required attempts at more invasive airway procedures (retrograde
intubation and cricothyrotomy). The intubating laryngeal mask airway was used
as a rescue method 5 times after failure of multiple methods, with successful
oxygenation, ventilation, and intubation through the laryngeal mask airway in
all 5 patients. All patients were successfully intubated.
CONCLUSION:
In this series of ED patients who were intubated because of angioedema,
emergency physicians used a range of methods to successfully manage the airway.
These observations provide key lessons for the emergency airway management of
these critical patients.
16. Epinephrine Concentrations Sufficient in EpiPens Long After
the Expiration Date
Cantrell FL,
et al. Ann Intern Med. 2017 May 9 [Epub ahead of print]
Background:
Interest and outrage have been mounting over dramatic price increases for the
emergency-use epinephrine autoinjection device EpiPen (Mylan). Since 2007, the
price of this potentially lifesaving medication has risen more than 400%. This
sharp increase has caused patients to ask health care practitioners whether
they can use expired EpiPens because they cannot afford to replace them.
Objective: To
determine whether EpiPens expired up to 50 months retain their stated potency.
Methods: Over
2 weeks, patients and practitioners at a community clinic were asked to provide
unused, expired EpiPens. All pens were examined for color changes and
expiration date. Two separate aliquots of each EpiPen's content were
quantitatively analyzed for epinephrine concentrations by liquid chromatography
(Agilent 1260 Infinity II LC, Agilent Technologies)–tandem mass spectrometry
(Triple Quad 5500, AB SCIEX). Epinephrine was monitored using 2 transitions
(mass–charge ratio, 184.1 to 107.0 and 184.1 to 166.0) and quantified by
isotope dilution using epinephrine-d6 as an internal standard.
Results: We
collected and analyzed 31 expired EpiPens (epinephrine, 1 mg/mL) and 9 EpiPen
Jrs (epinephrine, 0.5 mg/mL) (Table). None was discolored. All were 1 to 50
months past their expiration dates. Nineteen of the EpiPens (65%) and 5 of the
EpiPen Jrs (56%) contained at least 90% of their stated amount of epinephrine.
Discussion: Studies have shown that many medications retain full potency up to 40 years beyond their expiration dates (1). However, these studies rarely involve biological agents like epinephrine, which may not maintain their activity as long as other medications. Although medications in the United States are typically assigned expiration dates up to 3 years after manufacture, EpiPens are typically labeled with an expiration date of 18 months or less. One study found that expired EpiPens retained at least 50% of their stated amount of epinephrine up to 90 months past expiration (2), and another found that those less than 25 months past expiration contained at least 90% of the labeled amount (3).
The U.S. Food and Drug Administration permits most medications marketed in the United States to contain 90% to 110% of the labeled concentration of the active ingredients (4). In this study, approximately two thirds of the expired EpiPens and more than half of the expired EpiPen Jrs met this standard and all contained at least of 80% of their labeled concentrations. These findings are important because dosing recommendations for out-of-hospital treatment of anaphylaxis, which are based on anecdotal experience, specify a maximum initial dose of 0.2 to 0.5 mg in adults and 0.01 mg/kg of body weight (with a maximum total dose of 0.3 mg/kg) in children (5). Given that each EpiPen and EpiPen Jr delivers a dose of 3 mL, all of the products tested should deliver a dose within the recommended initial range.
In summary, our data show that EpiPen products can retain substantial amounts of epinephrine well beyond their expiration dates. Although we observed declining concentrations of epinephrine over time, we expect that the dose available 50 months after expiration would still provide a beneficial pharmacologic response. Thus, we conclude that the process for establishing expiration dates for EpiPens should be revised and that, in the setting of outpatient anaphylaxis without other therapeutic alternatives, patients and caregivers should consider the potential benefits of using an expired EpiPen.
Discussion: Studies have shown that many medications retain full potency up to 40 years beyond their expiration dates (1). However, these studies rarely involve biological agents like epinephrine, which may not maintain their activity as long as other medications. Although medications in the United States are typically assigned expiration dates up to 3 years after manufacture, EpiPens are typically labeled with an expiration date of 18 months or less. One study found that expired EpiPens retained at least 50% of their stated amount of epinephrine up to 90 months past expiration (2), and another found that those less than 25 months past expiration contained at least 90% of the labeled amount (3).
The U.S. Food and Drug Administration permits most medications marketed in the United States to contain 90% to 110% of the labeled concentration of the active ingredients (4). In this study, approximately two thirds of the expired EpiPens and more than half of the expired EpiPen Jrs met this standard and all contained at least of 80% of their labeled concentrations. These findings are important because dosing recommendations for out-of-hospital treatment of anaphylaxis, which are based on anecdotal experience, specify a maximum initial dose of 0.2 to 0.5 mg in adults and 0.01 mg/kg of body weight (with a maximum total dose of 0.3 mg/kg) in children (5). Given that each EpiPen and EpiPen Jr delivers a dose of 3 mL, all of the products tested should deliver a dose within the recommended initial range.
In summary, our data show that EpiPen products can retain substantial amounts of epinephrine well beyond their expiration dates. Although we observed declining concentrations of epinephrine over time, we expect that the dose available 50 months after expiration would still provide a beneficial pharmacologic response. Thus, we conclude that the process for establishing expiration dates for EpiPens should be revised and that, in the setting of outpatient anaphylaxis without other therapeutic alternatives, patients and caregivers should consider the potential benefits of using an expired EpiPen.
17. Efficacy and Safety of Tranexamic Acid in Prehospital
Traumatic Hemorrhagic Shock: Outcomes of the Cal-PAT Study
Neeki MM, et
al. WJEM 2017 April 19 [Epub ahead of print]
Introduction:
The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to
assess the safety and impact on patient mortality of tranexamic acid (TXA)
administration in cases of trauma-induced hemorrhagic shock. The current study
further aimed to assess the feasibility of prehospital TXA administration by
paramedics within the framework of North American emergency medicine standards
and protocols.
Methods: This
is an ongoing multi-centered, prospective, observational cohort study with a
retrospective chart-review comparison. Trauma patients identified in the
prehospital setting with signs of hemorrhagic shock by first responders were
administered one gram of TXA followed by an optional second one-gram dose upon
arrival to the hospital, if the patient still met inclusion criteria. Patients
administered TXA make up the prehospital intervention group. Control group
patients met the same inclusion criteria as TXA candidates and were matched
with the prehospital intervention patients based on mechanism of injury, injury
severity score, and age. The primary outcomes were mortality, measured at 24
hours, 48 hours, and 28 days. Secondary outcomes measured included the total
blood products transfused and any known adverse events associated with TXA
administration.
Results: We
included 128 patients in the prehospital intervention group and 125 in the
control group. Although not statistically significant, the prehospital
intervention group trended toward a lower 24-hourmortality rate (3.9% vs 7.2%
for intervention and control, respectively, p=0.25), 48-hour mortality rate
(6.3%vs 7.2% for intervention and control, respectively, p=0.76), and 28-day
mortality rate (6.3% vs 10.4% for intervention and control, respectively,
p=0.23). There was no significant difference observed in known adverse events
associated with TXA administration in the prehospital intervention group and
control group. A reduction in total blood product usage was observed following
the administration of TXA (control: 6.95 units; intervention: 4.09 units;
p=0.01).
Conclusion:
Preliminary evidence from the Cal-PAT study suggests that TXA administration
may be safe in the prehospital setting with no significant change in adverse
events observed and an associated decreased use of blood products in cases of
trauma-induced hemorrhagic shock. Given the current sample size, a statistically
significant decrease in mortality was not observed. Additionally, this study
demonstrates that it may be feasible for paramedics to identify and safely
administer TXA in the prehospital setting.
Full-text
(free): http://escholarship.org/uc/item/92q4f24b#
18. All NSAIDs Confer Risk of AMI during First Week of Use
by Crystal
Phend. Senior Associate Editor, MedPage Today. May 12, 2017
After
PRECISION [see below] leveled the playing field for heart risk among
nonsteroidal anti-inflammatory drugs (NSAIDs) in a randomized setting, the
question of risk with how people really use these painkillers in the real world
still wasn't answered.
So
researchers did a Bayesian analysis on individual patient data from healthcare
database studies to delve into the risk of acute MI specifically in a study
reported in BMJ [also below].
Taking any
dose of NSAIDs for even one week was associated with an increased risk of MI.
As in PRECISION, naproxen didn't earn the cardiovascular safety reputation it
has had among NSAIDs. The odds ratios for MI (95% credible intervals) versus no
NSAID use in the prior year were:
- 1.24 (0.91 to 1.82) for celecoxib (Celebrex)
- 1.48 (1.00 to 2.26) for ibuprofen
- 1.50 (1.06 to 2.04) for diclofenac
- 1.53 (1.07 to 2.33) for naproxen
- 1.58 (1.07 to 2.17) for rofecoxib (Vioxx, withdrawn)
Higher doses
conferred higher risk; but use for longer than one month didn't appear more
risky than shorter use.
"Given
that the onset of risk of acute myocardial infarction occurred in the first
week and appeared greatest in the first month of treatment with higher
doses," the group concluded, "prescribers should consider weighing
the risks and benefits of NSAIDs before instituting treatment, particularly for
higher doses."
A.
Risk of AMI with NSAIDs in real world use: bayesian meta-analysis of individual
patient data.
Bally M, et al.
BMJ. 2017 May 9;357:j1909
Objective To
characterise the determinants, time course, and risks of acute myocardial
infarction associated with use of oral non-steroidal anti-inflammatory drugs
(NSAIDs).
Design
Systematic review followed by a one stage bayesian individual patient data
meta-analysis.
Data sources
Studies from Canadian and European healthcare databases.
Review
methods Eligible studies were sourced from computerised drug prescription or
medical databases, conducted in the general or an elderly population,
documented acute myocardial infarction as specific outcome, studied selective
cyclo-oxygenase-2 inhibitors (including rofecoxib) and traditional NSAIDs,
compared risk of acute myocardial infarction in NSAID users with non-users,
allowed for time dependent analyses, and minimised effects of confounding and
misclassification bias. Exposure and outcomes Drug exposure was modelled as an
indicator variable incorporating the specific NSAID, its recency, duration of
use, and dose. The outcome measures were the summary adjusted odds ratios of
first acute myocardial infarction after study entry for each category of NSAID
use at index date (date of acute myocardial infarction for cases, matched date
for controls) versus non-use in the preceding year and the posterior
probability of acute myocardial infarction.
Results A
cohort of 446 763 individuals including 61 460 with acute myocardial infarction
was acquired. Taking any dose of NSAIDs for one week, one month, or more than a
month was associated with an increased risk of myocardial infarction. With use
for one to seven days the probability of increased myocardial infarction risk
(posterior probability of odds ratio above 1.0) was 92% for celecoxib, 97% for
ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding
odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib,
1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53
(1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater
risk of myocardial infarction was documented for higher dose of NSAIDs. With
use for longer than one month, risks did not appear to exceed those associated
with shorter durations.
Conclusions
All NSAIDs, including naproxen, were found to be associated with an increased
risk of acute myocardial infarction. Risk of myocardial infarction with
celecoxib was comparable to that of traditional NSAIDS and was lower than for
rofecoxib. Risk was greatest during the first month of NSAID use and with
higher doses.
B.
Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis.
Nissen SE, et
al. PRECISION Trial Investigators. N Engl J Med. 2016 Dec 29;375(26):2519-29.
BACKGROUND:
The cardiovascular safety of celecoxib, as compared with nonselective
nonsteroidal antiinflammatory drugs (NSAIDs), remains uncertain.
METHODS:
Patients who required NSAIDs for osteoarthritis or rheumatoid arthritis and
were at increased cardiovascular risk were randomly assigned to receive
celecoxib, ibuprofen, or naproxen. The goal of the trial was to assess the
noninferiority of celecoxib with regard to the primary composite outcome of
cardiovascular death (including hemorrhagic death), nonfatal myocardial infarction,
or nonfatal stroke. Noninferiority required a hazard ratio of 1.12 or lower, as
well as an upper 97.5% confidence limit of 1.33 or lower in the
intention-to-treat population and of 1.40 or lower in the on-treatment
population. Gastrointestinal and renal outcomes were also adjudicated.
RESULTS: A
total of 24,081 patients were randomly assigned to the celecoxib group (mean
[±SD] daily dose, 209±37 mg), the naproxen group (852±103 mg), or the ibuprofen
group (2045±246 mg) for a mean treatment duration of 20.3±16.0 months and a
mean follow-up period of 34.1±13.4 months. During the trial, 68.8% of the
patients stopped taking the study drug, and 27.4% of the patients discontinued
follow-up. In the intention-to-treat analyses, a primary outcome event occurred
in 188 patients in the celecoxib group (2.3%), 201 patients in the naproxen
group (2.5%), and 218 patients in the ibuprofen group (2.7%) (hazard ratio for
celecoxib vs. naproxen, 0.93; 95% confidence interval [CI], 0.76 to 1.13;
hazard ratio for celecoxib vs. ibuprofen, 0.85; 95% CI, 0.70 to 1.04; P less
than 0.001 for noninferiority in both comparisons). In the on-treatment
analysis, a primary outcome event occurred in 134 patients in the celecoxib
group (1.7%), 144 patients in the naproxen group (1.8%), and 155 patients in
the ibuprofen group (1.9%) (hazard ratio for celecoxib vs. naproxen, 0.90; 95%
CI, 0.71 to 1.15; hazard ratio for celecoxib vs. ibuprofen, 0.81; 95% CI, 0.65
to 1.02; P less than 0.001 for noninferiority in both comparisons). The risk of
gastrointestinal events was significantly lower with celecoxib than with
naproxen (P=0.01) or ibuprofen (P=0.002); the risk of renal events was
significantly lower with celecoxib than with ibuprofen (P=0.004) but was not
significantly lower with celecoxib than with naproxen (P=0.19).
CONCLUSIONS:
At moderate doses, celecoxib was found to be noninferior to ibuprofen or
naproxen with regard to cardiovascular safety.
19. US in the ED
A.
Diagnostic Value and Effect of Bedside US in Acute Appendicitis in the ED
Gungor F, et
al. Acad Emerg Med. 2017 May;24(5):578-586.
OBJECTIVE:
Early and accurate diagnosis of acute appendicitis (AA) with ultrasound (US)
can minimize the morbidity and mortality of the patients. In this regard, US
can help emergency physicians (EPs) in the diagnosing process and clinical
decision making for AA. Therefore, we primarily aimed to evaluate the
effectiveness of point-of-care US (POCUS) in clinical decision making of EPs
for the diagnostic evaluation for AA in the emergency department (ED).
METHODS: The
study sample consisted of patients aged greater than 18 years who presented to
the ED with abdominal pain and underwent diagnostic evaluation for AA. All
patients were examined initially with POCUS by EPs and then with
radiology-performed US (RADUS) by radiologists. Pre- and post-POCUS median
diagnostic certainty values (MDCVs) for AA were determined with visual analog
scale (VAS) scores (0 = not present, 100 = certainly present) by POCUS
performers. Definitive diagnoses were determined by surgery, pathologic evaluation
of appendectomy specimens, or clinical follow-up results. The sensitivity,
specificity, positive likelihood ratio (PLR), and negative likelihood ratio
(NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for
MDCVs were compared.
RESULTS: A
total of 264 patients were included into the final analysis and 169 (64%) had a
diagnosis of AA. The sensitivity, specificity, PLR, and NLR of US examinations
were 92.3% (95% confidence interval [CI] = 87.2%-95.8%), 95.8% (89.5%-98.8%),
21.9 (8.4-57.2), and 0.08 (0.05-0.1) for POCUS and 76.9% (69.8-83%), 97.8%
(84.9-99.7%), 36.4 (9.25-144.3), and 0.24 (0.18-0.31) for RADUS, respectively.
Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (interquartile range
[IQR] = 50-65) and 95 (IQR = 20-98), respectively (p = 0.000).
CONCLUSION:
Point-of-care ultrasonography, when performed in ED for the diagnosis of AA,
has high sensitivity and specificity and had a positive impact on the clinical
decision making of EPs.
Related article: Magnetic Resonance
Imaging Vs US as the Initial Imaging Modality for Pediatric and Young Adult
Patients With Suspected Appendicitis
MRI was
associated with greater ED LOS and higher costs
B.
Point-of-care US for Nonangulated Distal Forearm Fractures in Children: Test
Performance Characteristics and Patient-centered Outcomes.
Poonai N, et
al. Acad Emerg Med. 2017 May;24(5):607-616.
OBJECTIVES:
Distal forearm fractures are the most common fracture type in children.
Point-of-care-ultrasound (POCUS) is increasingly being used, and preliminary
studies suggest that it offers an accurate approach to diagnosis. However,
outcomes such as pain, satisfaction, and procedure duration have not been
explored but may be salient to the widespread acceptance of this technology by
caregivers and children. Our objectives were to examine the test performance
characteristics of POCUS for nonangulated distal forearm injuries in children
and compare POCUS to x-ray with respect to pain, caregiver satisfaction, and
procedure duration.
METHODS: We
conducted a cross-sectional study involving children aged 4-17 years with a
suspected nonangulated distal forearm fracture. Participants underwent both
x-ray and POCUS assessment. The primary outcome was sensitivity between POCUS
and x-ray, the reference standard. Secondary outcomes included self-reported
pain using the Faces Pain Scale-Revised, caregiver satisfaction using a
five-item Likert scale, and procedure duration.
RESULTS:
POCUS was performed in 169 children of whom 76 were diagnosed with a fracture
including 61 buckle fractures. Sensitivity of POCUS for distal forearm
fractures was 94.7% (95% confidence interval [CI] = 89.7-99.8) and specificity
was 93.5% (95% CI = 88.6-98.5). POCUS was associated with a significantly lower
median (interquartile range [IQR]) pain score compared to x-ray: 1 (0-2) versus
2 (1-3), respectively (median difference = 0.5; 95% CI = 0.5-1; p less than
0.001) and no significant difference in median (IQR) caregiver satisfaction
score: 5 (0) versus 5 (4-5), respectively (median difference = 0, 95% CI = 0, p
= 1.0). POCUS was associated with a significantly lower median (IQR) procedure
duration versus x-ray: 1.5 (0.8-2.2) minutes versus 27 (15-58) minutes,
respectively (median difference = 34.1, 95% CI = 26.8-41.5, p less than 0.001).
CONCLUSIONS:
Our findings suggest that POCUS assessment of distal forearm injuries in
children is accurate, timely, and associated with low levels of pain and high
caregiver satisfaction.
C.
ACEP US Guidelines: Emergency, Point-of-Care and Clinical US Guidelines in
Medicine
No authors
listed. Ann Emerg Med. 2017 May;69(5):e27-e54.
Section 1 – Introduction by Diku P.
Mandavia MD, Vivek S. Tayal MD
Ultrasound
(US) has become an integral modality in emergency care in the United States
during the last two decades. Since the last update of these guidelines in 2008,
US use has expanded throughout clinical medicine and established itself as a
standard in the clinical evaluation of the emergency patient. There is a wide
breadth of recognized emergency US applications offering advanced diagnostic
and therapeutic capability benefit to patients across the globe. With its low
capital, space, energy, and cost of training requirements, US can be brought to
the bedside anywhere a clinician can go, directly or remotely. The use of US in
emergency care has contributed to improvement in quality and value,
specifically in regards to procedural safety, timeliness of care, diagnostic
accuracy, and cost reduction. In a medical world full of technological options,
US fulfills the concept of “staged imaging,” where the use of US first can
answer important clinical questions accurately without the expense, time, or
side effects of advanced imaging or invasive procedures.
Emergency
physicians have taken the leadership role for the establishment and education
of bedside, clinical, point-of-care US use by clinicians in the United States
and around the world. Ultrasonography has spread throughout all levels of
medical education, integrated into medical school curricula, through residency,
to postgraduate education of physicians, and extended to other providers such
as nursing, advanced practice professionals, and prehospital providers. US
curricula in undergraduate medical education is growing exponentially due to
the leadership and advocacy of emergency physicians. US in emergency medicine
(EM) residency training has now been codified in the Accreditation Council for
Graduate Medical Education (ACGME) Next Accreditation System (NAS). Emergency
US specialists have created the foundation of a subspecialty of ultrasonography
that provides the expertise for establishing clinical practice, educating
across the educational spectrum, and researching the wide range of applications
of ultrasonography. Within healthcare institutions and healthcare systems,
emergency physicians are now leading institutional clinical US programs that
have used this guideline as a format for multidisciplinary programs.
US imaging
and information systems have become more sophisticated and digital over the
last decade allowing emergency US examinations to have versatility, mobility
and integration. US hardware for emergency care has become more modular, smaller,
and powerful, ranging from smartphone size to slim, cart-based systems
dedicated to the emergency medicine market. US hardware has evolved to allow
on-machine reporting, wireless connectivity and electronic medical record (EMR)
and picture archiving and communication system (PACS) integration. A new
software entity, US management systems, was created to provide administrative
functionality and the integration of US images into electronic records.
Emergency physician expertise was integral in the development of these hardware
and software advances.
These
guidelines reflect the evolution and changes in the evolving world of emergency
medicine and the growth of US practice. Themes of universality of practice,
educational innovation, core credentialing, quality improvement, and value
highlight this new edition of the guidelines. The ultimate mission of providing
excellent patient care will be enhanced by emergency physicians and other
clinicians being empowered with the use of US.
20. Antibiotic prescription strategies and adverse outcome for
uncomplicated lower respiratory
tract
infections: prospective cough complication cohort (3C) study
Bottom line: Don’t treat “bronchitis”
with antibiotics
Little P, et
al. BMJ 2017;357:j2148
Objective To
assess the impact on adverse outcomes of different antibiotic prescribing
strategies for lower respiratory tract infections in people aged 16 years or
more.
Design
Prospective cohort study.
Setting UK
general practice.
Participants
28 883 patients with lower respiratory tract infection; symptoms, signs, and
antibiotic prescribing strategies were recorded at the index consultation.
Main outcome
measures The main outcomes were reconsultation with symptoms of lower
respiratory tract infection in the 30 days after the index consultation,
hospital admission, or death. Multivariable analysis controlled for an
extensive list of variables related to the propensity to prescribe antibiotics
and for clustering by doctor.
Results Of
the 28 883 participants, 104 (0.4%) were referred to hospital for radiographic
investigation or admission, or both on the day of the index consultation, or
were admitted with cancer. Of the remaining 28 779, subsequent hospital
admission or death occurred in 26/7332 (0.3%) after no antibiotic prescription,
156/17 628 (0.9%) after prescription for immediate antibiotics, and 14/3819
(0.4%) after a prescription for delayed antibiotics. Multivariable analysis
documented no reduction in hospital admission and death after immediate
antibiotics (multivariable risk ratio 1.06, 95% confidence interval 0.63 to
1.81, P=0.84) and a non-significant reduction with delayed antibiotics (0.81,
0.41 to 1.64, P=0.61). Reconsultation for new, worsening, or non-resolving
symptoms was common (1443/7332 (19.7%), 4455/17 628 (25.3%), and 538/3819
(14.1%), respectively) and was significantly reduced by delayed antibiotics
(multivariable risk ratio 0.64, 0.57 to 0.72, P less than 0.001) but not by
immediate antibiotics (0.98, 0.90 to 1.07, P=0.66).
Conclusion
Prescribing immediate antibiotics may not reduce subsequent hospital admission
or death for young people and adults with uncomplicated lower respiratory tract
infection, and such events are uncommon. If clinicians are considering
antibiotics, a delayed prescription may be preferable since it is associated
with a reduced number of reconsultations for worsening illness.
21. Opioid Prescribing
A.
Opioid Prescribing by Emergency Physicians and Risk of Long-Term Use
Menchine M,
Kea B. N Engl J Med 2017; 376:1895-1896.
To the
Editor: Barnett et al. (Feb. 16 issue)1 affirm a key hypothesis: seemingly
random clinical exposure to opioids facilitates long-term use, at least among
Medicare patients. Without careful inspection, readers may incorrectly
interpret this finding to suggest that emergency physicians are key drivers of
the opioid epidemic. Nationally, emergency department encounters account for
only 5% of all opioids prescribed, even though they constitute more than 10% of
all ambulatory visits.2
This study
shows that the risk of long-term opioid use after treatment in an emergency
department by a “high-intensity prescriber” is small at 1.51%, as compared with
a 1.16% risk associated with treatment by a “low-intensity prescriber.”
Together these data suggest that interventions in the emergency department to
reduce prescribing have a low potential to reduce long-term opioid use.
Furthermore, the study is seriously limited, since it does not and cannot
compare this effect size against that of providers in other clinical settings
where high-dose and long-term opioid prescribing is much more prevalent (e.g.,
office-based practices that account for greater than 84% of opioid
prescriptions).3 Understanding this crucial limitation is key to ensuring that
policies do not unjustly focus on opioid prescribing in emergency departments,
but rather target the problem of overprescribing of opioids in a comprehensive,
multidisciplinary manner.
B.
Report shows drop in pain medication prescribing
A
QuintilesIMS Institute report showed that in 2016 acetaminophen/hydrocodone
dropped to the fourth most prescribed drug in the US, reflecting a 34% decrease
in the number of prescriptions since 2012. The report also showed a decrease in
prescriptions for all pain medications for the second year a row.
22. Micro Bits
AA. Calling All Clean Freaks! Pay More
Attention to Floors, Socks, and Phones
by Angela
Ballard, RN, EMT, The Daily Nurse | May 15, 2017
The last time
you walked into a patient’s hospital room, what was touching the floor? A purse
or briefcase? A cell phone charger? The call button? The TV remote? A blood
pressure cuff? Pulse ox? Water bottle?
I don’t know
about you, but whenever I see high-touch items like these casually dropped or
placed on the hospital floor, I cringe. Until recently, however, I didn’t have
any data to back up my revulsion.
For better or
for worse, I do now. Yes, bacteria and viruses really can get transferred from
patients, to floors, and back up again to other patients, health care
providers, and even visitors.
According to
a recent study published in the American Journal of Infection Control, patient
room floors in five Cleveland-area hospitals were often contaminated with
health care-associated pathogens, and objects on the floor frequently resulted
in the transfer of pathogens to hands.
Of particular
concern, the study found that C. difficile (Clostridium difficile) was the most
frequently recovered pathogen from patient room floors. The frequency of
contamination was similar in each of the five hospitals studied and in patient
rooms and bathrooms, alike.
How should
this impact your day-to-day practice? Here’s what I think…
The remainder
of the essay: http://dailynurse.com/calling-clean-freaks-pay-attention-floors-socks-phones/
A. Naked mole rats can survive 18
minutes without oxygen. Here’s how they do it
Science Mag: http://www.sciencemag.org/news/2017/04/naked-mole-rats-can-survive-18-minutes-without-oxygen-here-s-how-they-do-it
B. AAFP Endorses ACP Guideline on
Treating Osteoporosis
May 11, 2017
03:17 pm Chris Crawford – An estimated 54 million adults in the United States
have low bone density or osteoporosis. And about half of all Americans older
than 50 are at risk for osteoporotic fracture.
In response
to this highly prevalent health problem, the American College of Physicians
(ACP) has recommended in an evidence-based clinical practice guideline (annals.org)
that physicians offer pharmacologic therapy with a bisphosphonate --
alendronate (Fosamax), risedronate (Actonel, Atelvia) or zoledronic acid
(Reclast) -- or the biologic agent denosumab (Prolia) to reduce the risk for
hip and vertebral fractures in women who have known osteoporosis.
The AAFP has
endorsed the guideline, which includes additional recommendations on the
appropriate length of pharmacologic therapy in osteoporotic women and against
the use of menopausal estrogen therapy to treat the condition. The guideline
also recommends against bone density monitoring during treatment and makes
specific recommendations for men with clinically recognized osteoporosis and
older women with osteopenia.
ACP
Guideline: http://annals.org/aim/article/2625385/treatment-low-bone-density-osteoporosis-prevent-fractures-men-women-clinical
C. FDA finds no link between
fluoroquinolones and retinal, aortic problems
The FDA has
issued a drug safety communication update informing the public that its review
of patient cases and study findings found no evidence of an association between
fluoroquinolone use and retinal detachment or aortic aneurysm and dissection.
The agency last year warned that using fluoroquinolones may lead to disabling
side effects and that the drugs should only be prescribed when patients have no
other treatment options.
D. AIDS treatments add years of life
expectancy
The latest
antiretroviral medications for AIDS can add 10 years of life expectancy to
young patients in the US and Europe, according to a study in The Lancet. Factors
include the use of less-toxic drug combinations and better options for
individuals with drug-resistant strains of HIV.
E. No arthroscopic surgery for
degenerative knee arthritis and meniscal tears: a clinical practice guideline
An expert
panel make a strong recommendation against the use of arthroscopy in nearly all
patients with degenerative knee disease, based on linked systematic reviews.
F. Weekend effect may be explained by
patient-level differences?
Walker AS, et
al. Mortality risks associated with emergency admissions during weekends and
public holidays: an analysis of electronic health records. Lancet. 2017 May 9 [Epub
ahead of print].
BACKGROUND:
Weekend hospital admission is associated with increased mortality, but the
contributions of varying illness severity and admission time to this weekend
effect remain unexplored…
INTERPRETATION:
Adjustment for routine test results substantially reduced excess mortality
associated with emergency admission at weekends and public holidays. Adjustment
for patient-level factors not available in our study might further reduce the
residual excess mortality, particularly as this clustered around midday at
weekends. Hospital workload was not associated with mortality. Together, these
findings suggest that the weekend effect arises from patient-level differences
at admission rather than reduced hospital staffing or services.
Full-text
(free): http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30782-1/fulltext
G. Avoid Processed Red Meat
Etemadi A, et
al. Mortality from different causes associated with meat, heme iron, nitrates,
and nitrites in the NIH-AARP Diet and Health Study: population based cohort
study. BMJ 2017;357:j1957
…Conclusions
The results show increased risks of all cause mortality and death due to nine
different causes associated with both processed and unprocessed red meat,
accounted for, in part, by heme iron and nitrate/nitrite from processed meat.
They also show reduced risks associated with substituting white meat,
particularly unprocessed white meat.
H. And Eat at Home: Cooking at home
positively affects health and finances
This study
examined the frequency of home-cooked dinners versus eating out in relation to
the Healthy Eating Index (HEI) and food expenditures. Frequent at-home cooking
was associated with higher HEI and reduced per capita food expenditures, while
frequent eating out was associated with lower HEI and significantly higher per
capita food expenditures. Household characteristics associated with frequent
home-cooked dinners include being married, being unemployed, having a large
household, and having children aged less than 12 years. Education and income
were not associated with frequency of home cooking.
I1. Evolocumab and Clinical Outcomes in
Patients with Cardiovascular Disease
In our trial,
inhibition of PCSK9 with evolocumab on a background of statin therapy lowered
LDL cholesterol levels to a median of 30 mg per deciliter (0.78 mmol per liter)
and reduced the risk of cardiovascular events. These findings show that
patients with atherosclerotic cardiovascular disease benefit from lowering of
LDL cholesterol levels below current targets.
I2. No Effect of Reminder Devices on
Medication Adherence: The REMIND Randomized Clinical Trial
J. Implicit Bias in Academic Medicine:
#WhatADoctorLooksLike
On October 9,
2016, Tamika Cross posted to Facebook the description of her experience on
Delta flight DL945, flying from Detroit to Houston, when she offered to assist
with an inflight medical emergency. Dr Cross, an African American woman, is a
graduate of Meharry Medical College and is currently a postgraduate year (PGY)
4 physician in obstetrics and gynecology, serving as administrative chief
resident at the University of Texas in Houston. Her offers of assistance were
first met with patronizing dismissal and subsequently, even when she had
persuaded the flight crew that she was a physician, were declined in favor of
those of a white man, who offered no evidence that he was a physician. The post
went viral #WhatADoctorLooksLike and was followed by a chorus of similar
experiences related by other dark-skinned women whose claims that they were
physicians were discounted on the basis of their skin color, sex, or both…
K. Same-hospital readmission tied to
better HF survival
A study found
that Canadian patients with heart failure who were readmitted within 30 days to
the same hospital had 11% lower odds of mortality during the hospital stay and
tended to be discharged one day sooner than patients admitted to a different
hospital than where they originally received care. Researchers stressed the
importance of continuity of care for chronic conditions, particularly access to
pertinent patient information that may sometimes not be included in discharge
summaries.
L. Mortality and early management in
elderly acute myocardial infarction patients
One-year
mortality of elderly patients with acute myocardial infarction has decreased
over the past 15 years. This improvement can be partially credited to the
increasing use of recommended management strategies.
M. Study looks at pediatric ED visits
for cotton swab-related ear injuries
More than
263,000 US youths younger than 18, or about 34 children daily, were brought to
the emergency department due to cotton tip applicator-related ear injuries
between 1990 and 2010, and nearly two-thirds of the patients were younger than
8, researchers reported in the Journal of Pediatrics. The findings also showed
that foreign body sensation, perforated ear drum and soft tissue injury were
the most prevalent injuries.
N. New guidelines update pediatric
fruit juice recommendation
Infants
younger than age 1 shouldn't be given any fruit juice, while youths ages 1 to
3, 4 to 6 and 7 to 18 should drink no more than 4 ounces, 4 to 6 ounces and 8
ounces of 100% fruit juice daily, respectively, according to an updated
American Academy of Pediatrics policy statement in Pediatrics. The
recommendations also urged pediatricians to support policies to lower fruit
juice consumption and boost whole fruit intake among children.
O. Research links older physicians to
higher patient mortality
Hospitalized
patients treated by older physicians had a higher 30-day mortality rate,
compared with those treated by younger doctors, according to a study in The
BMJ. The study also found that the association was not seen among older
physicians with high patient volume and that 30-day readmission rates were not
affected by physician age.
P. Research analyzes need for routine
cholesterol testing
A study in the
Annals of Internal Medicine suggests many adults under age 40 may not need
routine cholesterol tests. Researchers looked at data on 9,600 adults ages 30
to 49 and found that for nonsmokers with normal blood pressure, there was
little heightened risk of a heart attack over the next decade.
